Pharmacy-level barriers to opioid overdose prevention: availability and accessibility of naloxone and buprenorphine–naloxone in high-risk Texas counties

Texas has experienced a dramatic increase in unintentional opioid deaths over the past decade, underscoring the urgent need for effective prevention strategies. Access to naloxone nasal spray (NNS) and buprenorphine–naloxone (BUP/NX) is essential for reducing opioid-related fatalities. NNS, a µ-opioid receptor antagonist, rapidly reverses overdoses, while BUP/NX, a partial opioid agonist/antagonist, reduces cravings and withdrawal, decreasing opioid-related and all-cause mortality and improving treatment retention. Despite regulatory advances, barriers such as limited pharmacy stocking, restrictive policies, stigma, and prohibitive costs persist. The availability of NNS and BUP/NX in contiguous metropolitan Texas counties with high opioid-related overdose mortality rates remains underexamined. This study assesses the availability and accessibility of these medications in retail pharmacies across high-risk southeast Texas counties with some of the highest opioid overdose death rates in the state. Between April 30, 2024 and June 6, 2024, a cross-sectional telephone survey was conducted among community pharmacies in Brazoria, Galveston, Chambers, Jefferson, and Orange counties in Texas. Data were collected on medication stock, ordering timelines, and pricing. BUP/NX and NNS availability and accessibility across pharmacies were compared using Fisher’s exact test (p < 0.05). Of 309 pharmacies surveyed (90% response rate), 198 were included in the analysis. Same-day availability of NNS was reported by 74% of pharmacies, although 54% imposed purchase restrictions. Chain pharmacies demonstrated the highest same-day availability (90%) and lowest prices (82%). BUP/NX was available same-day in only 38% of surveyed pharmacies, with the highest same-day availability rate in chains (44%) and lowest in “other” pharmacies (22%). Geographic disparities were noted, with Galveston and Brazoria counties showing greater access. Barriers to stocking BUP/NX included supply chain issues (n = 18), unclear reasons (n = 12), internal policies (n = 11), low demand (n = 9), controlled substance limits (n = 5), and stigma (n = 5). Significant gaps remain in the availability and accessibility of NNS and BUP/NX in southeast Texas community pharmacies. Persistent barriers including supply chain limitations, internal policies, and stigma continue to impede timely access to these lifesaving medications. Reducing opioid overdose deaths requires coordinated efforts among pharmacies, suppliers, and regulators to ensure equitable MOUD access in Texas.